We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference:

The following transcription is of the opening sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i.

Allan Wilke, MD, Western Michigan University [Dr Wilke is a Senior Fellow of the National Conferences on Primary Heatlh Care Access]: My first reaction is that I understand now why David Sundwall was asked to be the keynote speaker and not me. It was a wonderful discussion, with a very concise review of ACA and a nice review of Utah’s progress in healthcare reform, or health insurance reform. Certainly the ideas that you brought forth as to where the prognoses are, are thought provoking.

David Sundwall, MD (left) and Allan Wilke, MD (right)

I think that a lot of us are feeling in limbo about where we are with ACA, health insurance reform and healthcare reform in general.

We’d like to be a little more secure in where we’re going with this. It feels to me that we’re playing the best hand with the cards that we’ve been dealt, but that we aren’t looking far enough out into the future to know how it will work out.

What kinds of plans can we put into place? What can we depend upon to occur? I guess I would look at specifics such as the part of ACA that promotes teaching health centers.

As most of you know, at the very last moment instead of funding the residency positions out of Medicare they were moved to the Department of Health and Human Services Health Resources and Services Administration [that Dr Sundwall once administered], but only for five years.

As a person that has to deal with residents and expanded residency positions, five years is nothing. Not knowing that I’m going to have a continued revenue stream after that means that I can’t plan on an expansion that is funded for certain only in the first few years. I really can’t do that kind of planning, knowing that I don’t have any alternative plans for replacing the funds in the out-years.

David Sundwall, MD [Dr Sundwall is a Senior Fellow of the National Conferences]You are absolutely right that there is not sufficient attention in ACA to long term issues. I can tell you because I worked on the United States Senate staff for five years; I helped write a lot of health law.

This process was pathetic! There was no conference committee. There was not a single Republican who voted for the bill. It’s a partisan mess. I say that because it never got a chance to iron out the kinks in it.

Some of these issues could have been attended to if they had gone to conference. It was a clever ploy based on “reconciliation rules” that the Democrat leadership use to ram the bill through. Recall the quote of Speaker Nancy Pelosi who said “Don’t worry about it, We’ll read it after we pass it.”

Sad! Congressional legislation is a complicated process. I know how ACA happened. If you work in the Senate and you’ve got a pet project; you get them slipped into the bill. That’s what they did as a Congressional staffer. I had my pets, like Title Seven, and the Public Health Service. I was a champion of those programs in the early 80’s. I spent a lot of attention on them.

A lot of members and staffers added their provisions to this bill that never got the light of day before it was sent to the White House. We’re going to be cleaning up these complexities and addressing matters like cost containment or medical liability for long-term conditions for years to come.

Lead Question: Perry Pugno, MD, MPH, American Academy of Family Physicians, Leawood, Kansas [Dr Pugno is a Senior Fellow of the National Conferences]: This morning we started out hearing that we’ve been calling for a need for a generalist-based healthcare system since the 1930’s. In fact I recall reading in the 80’s; I think it was a treatise written by this guy named Doctor John Geyman who was articulating a conversation Dr Osler had 100 years earlier that said the same thing.

We’ve come to realize this, that this need, we’ve got, we’re drowning in data that proves that a generalist healthcare system is what we need. We acknowledge this growing importance of the interface between generalist care and public health – that the social determinants of health are more and more important along the way.

You acknowledged this morning that there’s very little cost containment material in the ACA. I’d really, really, really like to hear something optimistic that’s going to tell me that something’s going to happen with time.

But my diagnosis our country with pernicious partisan politics; and so I’m worried that the feds are not going to make it happen and I have, I’m seeing bits and pieces of evidence; and you just articulated some of it from Utah, that the states are going to grab hold of what few resources they can pull from the feds and that maybe the solution to some of this stuff will come from the states rather than the feds. I’d like your reaction to that.

Dr Sundwall:I thought I was kind of optimistic. I was trying to tell you we’ve moved down the road. We just have gone about, you know a few miles; we’re not far on our journey. But we are getting there.

I do sincerely appreciate that more people having insurance is a good thing. That’s good for public health, good for personal health; but as far as the prognosis, I think we’ll get over this bad patch.

I think that the Tea Party folks’ antigovernment rhetoric is wearing so thin and there just are many of us who are just appalled by the kind of obstructionist kinds of things. So I’m hopeful that we’re going to see some change. I’m not sure it’s going to happen soon.

But I think like this Time Magazine article the economic imperative is so strong that we do something about healthcare that I think we’ll get there. And I’m a proud American I think we can work this out.

In Washington State we hold out Utah as the model because their per capita healthcare costs are dramatically lower than Washington State. Can you tell me two or three reasons why you think that might be true?

Dr Sundwall: I can tell you in a nutshell. When I was Commissioner of Health I used to acknowledge to the legislature and other people that my job was much easier when you live in a state where half the people are afraid they’ll go to hell if they drink or smoke. (Go to hell if you drink. Boy am I going to get it!)

I’m being a little facetious, but the Mormon culture, that has its own health code against those smoking, alcohol and the like, is helpful. Aside from that, I think there is a culture of health that isn’t religious-based. We’re an outdoorsy folk. We’re kind of like Colorado! We enjoy relatively low obesity rates, although the statistical difference between states is not great. We’re fat too!

Donald Frey, Creighton University, Omaha, Nebraska:David, you’ve shown once again why you’re the nicest Republican I know! As you recall, I said that before to David a few years ago at a breakfast session, and one of our colleagues from the University of Washington said “David you’re the only Republican I know.”

My question is this. You’ve articulated a very, very well structured system to help give people choices with regards to the health insurance market.

From my view, one of the most difficult issues we contend with is that there’s a fundamental difference between a health insurance market and a health care market. The two are not synonymous. Often, they can be at odds with one another.

To what extent do you think the system you’ve set up in Utah that in fact provides information that helps consumers make health insurance choices is really effective in terms of helping them make healthcare choices in the healthcare market?

Dr Sundwall:Well, that’s a hard question. I do think there’s an enormous amount of unhealthy behaviors for people to choose to you know, read or ignore. I honestly,

Here’s where I get skeptical, I don’t think that information drives insurance choices. I think it’s cost. When push comes to shove you buy the policy you can afford. If you are a young family that needs OB coverage, you buy a policy includes OB. You search out what you need at the best price.

Based on my own experience as a federal employee, when the annual open enrollment came around, I always looked at what had the lleast out of pocket cost for me. So I’m not sure that having a lot of information about healthcare options will cause people to make a choice related to health over a choice related to cost. I think they vote with their pocket book primarily.

Allan Wilke, MD, Western Michigan University School of Medicine:Arkansas’ state responses, as I understand it, is to purchase insurance for their poorest citizens. To me, that sounds like a good idea, but isn’t that what the health exchanges are supposed to do? As I understand the Arkansas plan, it will offer even less choice because someone will go out go out and purchase it for you.

It also sounds to me like Arkansas’ Republican administration has taken a good idea and putting lipstick on it and called it something else, so they didn’t have to say that they supported Obamacare.

Dr Sundwall: What you’re referring to is the waiver that Arkansas applied to CMS for. Although it has not actually been finalized, Secretary Sebelius has said good things about granting a waiver that would allow states to use their Medicaid money to purchase private health insurance for their citizens under the 138% poverty level. It would not be just a subsidy to buy private insurance, but to buy a policy for them in the private sector.

That of course appeals to Republicans. Your concern about what kind of policy are they going to get is a good one. If the plan that Arkansas purchases has to meet the minimum benefit standards that are in the law, it probably will be pretty good. So I think that it’s an experiment that’s worth playing out.

I can tell you in Utah the reason why I predicted they might go for the expansion is based on the fact that they might allow use of those public dollars to buy private insurance. So it’s an interesting twist and I think an attempt to diffuse some of the Republican criticism of Obamacare.

Marc Babitz, MD, Utah Department of Health [Dr Babitz is a Senior Fellow of the National Conferences]:I had the pleasure of working for David twice in my life – once at the federal level in HRSA, once at the State of Utah’s Department of Health.

Actually, he did my physical exam last week and he said I passed. I was so happy. I had to make sure he was certified for billing insurance.

Those of us in the audience know David as having been a very good and supportive Republican, but when it comes to Utah they actually thought he might be a Democrat.

I have a comment and a question. If 50% of our current providers were in primary care medicine/healthcare, I think the ACA would have a good chance of being successful. My fear is that with our current problem in primary care that the ACA is going to rapidly become bankrupt – just as we saw in Massachusetts. All those people who have insurance will need some place to go. There won’t be enough primary care providers to see them, so they’ll go to the emergency rooms and they’ll go to the subspecialist. They’ll have lots of procedures done, and the costs will skyrocket. What are your thoughts on my comment?

Dr Sundwall:I believe that your worries are justified.. Massachusetts bragged about their 99% coverage, their almost universal coverage in their state. But what has it done to cost containment? Nothing.

They now have a tiger by the tail with more people having insurance. By the way, a little prediction that I heard from a reliable source is; when the mandate kicks in and everybody has to go to insurance that if you are in an employer-based insurance plan your rates will state relatively the same, but for all those people who haven’t had insurance, there will be many of them who are going to be “poor risk”, so it is predicted that the rates of private insurance will go up double digits. Not only is ACA not a way to get cost containment, it might prove to be cost inflationary. That will be a problem.

If ACA were primary care based it would be helpful, but the workforce issues are unbelievably daunting. The primary care provisions that are currently in the ACA, if they do anything, it will be seven years down the road. ACA didn’t enact more training support for primary care. By 2014 we will have to have to have a lot more primary care docs to meet the act’s requirements, but it’s going to be years down the road before we do, so we’ve got a real workforce problem.

This will be our last question.

Robert Bowman, A. T. Still University School of Osteopathic Medicine, Mesa, Arizona; One quick comment. You have made reference to the link between better healthcare outcomes from health insurance in states like Utah, Colorado and Minnesota with favorable social determinants of health. So until you deal with those social determinants in less healthy communities, the emphasis on health insurance makes little sense.

My question relates to the corruption of processes intended to reform healthcare. Between the enactment of Medicare and Medicaid in 1965 and 1980 the emphasis on health access in those acts was so diluted as to no longer be a priority. It took about five years to defeat managed care; often because we didn’t have the primary care workforce to operate it.

It seems that even before the 2010 PPACA reforms were enacted, they were defeated. Do we have a chance against a very powerful corporate, multi-corporate lobby that gets more and more hundreds of billions of dollars design a healthcare system from which they directly profit?

Dr Sundwall:I’m not sure what the question is, but there’s no question that the Washington’s run by money and the poor and the needy don’t have a voice that’s anywhere comparable to the self-interest group. So that’s another thing in our society that’s troubling; even to some of us Republicans!